International Student APPLICATION FORM - Spotswood College

International StudentAPPLICATION FORMAll sections must be completed for application to be processedSPOTSWOOD COLLEGEPO Box 6116129 South RoadNew PlymouthNEW ZEALANDGloria HollandDirector of International StudentsTelephone: +64 6 751 2416Fax: +64 6 751 2418Mobile: +64 21 751 241Email: gho@spotswoodcollege.school.nzWebsite: www.spotswoodcollege.school.nz19 October 2012 Page 1

CONTACT DETAILSStudent Details(1) Surname / Family NameAttach a recentpassport sizephoto hereFirst name (s)Date of Birth (DD/MM/YYYY) Male Female Student’s cell phone numberHome Address (in your country)(2) Country of birth Country of citizenship(3) Ethnic group First languageDate of arrival in NZ Passport number Permanent resident in NZ?Present school attendingYesNoHave you attended any other educational institution in New Zealand? (Select one) Yes No if Yes please state:When __________________ Where _______________________________________________________________________________Student’s MotherSurname First Name(s) Phone FaxAddressE-mailStudent’s FatherSurname First Name(s) Phone FaxAddressE-mailStudent’s AgentName of Company or name of Agent Phone FaxAddressE-mailHealth/travel insurance is mandatory.Do you have health/travel insurance?YesNoIf No, do you want this organized throughSpotswood College?YesNoSelect insurance companyUnicareSouthern Cross· I agree to all details from sections (1) and (2) being given to the New Zealand Qualifications Authority for examination purposes:Yes· I agree that information as to school performance may be passed on to appropriate institutions as requested: Yes NoNoPlease ensure the following documents areincluded with this application.• Translated copies of school results• Letter of authorization from parents• Photocopy of passport• Completed medical report (page 4)• Letter of acceptance from guardian• Photocopy of student visa19 October 2012 Page 2

PROGRAMME SELECTIONAcademic courseStart date (select one) February JulyProposed entry levelYear 9 Year 10 Year 11Year 12 Year 13IELTS score (attach evidence of result)Please indicate your level of EnglishBeginner Elementary IntermediateUpper IntermediateState1) Name of your highest academic qualification2) The qualification you are currently enrolled inSubject Preferences1) ______________________________________________2) ______________________________________________3) ______________________________________________4) ______________________________________________5) ______________________________________________6) ______________________________________________Attach photocopies of your academic results for the last two years.Results must be translated into English.English language standards are required for entry into SpotswoodCollege International Programmes.State the name of the English test you have sat and the score.Enrolment Form Confirmation1) I/We confirm acceptance of the place offered by Spotswood College. I/We understand that the tuition, homestay (including transfer)and insurance fees must be paid in full in advance as requested, and in any case before the student commences at SpotswoodCollege.2) In the event of a cancellation prior to arrival in New Zealand, the cancellation policy applies. There is no refund of tuition fees for anystudent who withdraws from the course after course commencement. I/We have read and agree with the Spotswood College RefundPolicy. (Refer to Schedule of Refunds attached).3) I/We note and accept that all International Students must live with one of Spotswood College’s registered homestay families and underthe supervision of a Spotswood College-appointed Homestay Supervisor, throughout his/her course at Spotswood College. (Refer toHomestay Policy attached).4) I/We confirm that the material supplied in the application for admission is accurate and complete, and I/we understand that SpotswoodCollege may suspend my enrolment if false information has been supplied.5) I/We note and accept the requirements regarding payment of fees and refund polices and the conditions relating thereto.6) I/We agree to ensure that the student complies with Spotswood College’s Code of Behaviour (see attached).7) I/We note and accept that enrolment is subject to availability of places within the College and is conditional on all fees being paid in fullprior to the student commencing their studies at Spotswood College.8) I/We give permission for my son/daughter to take part in activities outside the classroom that have been arranged by the school,activities and travel undertaken with the host family and tours run by organisations specifically for International Students.9) I/We note and accept that International Students are not permitted to travel independently and unsupervised outside the NewPlymouth area.10) I/We note and accept that any travel not with the host family requires the permission of the Director of International Students and thewritten permission of a natural parent.11) I/We agree my son/daughter will not own/drive a car while attending Spotswood College.This document must be signed for the application to be processed._________________________________ _________________________________ __________________________Mother’s signature Father’s signature DatePlease forward your application by mail or fax to:Spotswood CollegeInternational Student DepartmentP O Box 6116New PlymouthNEW ZEALAND Fax +64 6 751 241819 October 2012 Page 3

HEALTH RECORDTo help us in the care of your son or daughter, please ask your doctor to answer the following questions aboutyour son’s/daughter’s health:Student surnameStudent first name(s)Family doctor’s name Phone Date of examinationHas the student ever suffered from:Tuberculosis Yes No Hepatitis A Yes NoEpilepsy Yes No Hepatitis B Yes NoDiabetes Yes No Asthma Yes NoAnorexia/Bulimia Yes No Rheumatic fever Yes NoAllergy* Yes No Medicine/drug allergies* Yes NoGive Details*Give Details*Any otherWhat treatment or medication does the student currently have?Does the student have any difficulty with:Sight Yes No Hearing Yes NoHas the student had the following vaccinations?Yes No Yes NoTuberculosis (BCG)Poliomyelitis (oral vaccine)When did the student last have a chest x-ray?Year:Place:Rubella (German measles)TetanusWhat were the results of the x-ray?Any further comment you may wish to addParent’s signature ___________________________________________________________Doctor’s signature __________________________________ Date ____________________19 October 2012 Page 4